* The 2016 ACIP Adult Immunization Schedule appears in Annals of Internal Medicine and on the Centers for Disease Control and Prevention Web site at www.cdc.gov/vaccines/schedules. An announcement summarizing changes in the 2016 adult immunization schedule is published concurrently in the Morbidity and Mortality Weekly Report. Readers can cite the 2016 adult immunization schedule as follows: Kim DK, Bridges CB, Harriman KH; Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practice recommended immunization schedule for adults aged 19 years or older: United States, 2016. Ann Intern Med. 2016;164:184-94. doi:10.7326/M15-3005

† The 2016 adult immunization schedule was prepared by the Advisory Committee on Immunization Practices (ACIP); ACIP Adult Immunization Work Group; David K. Kim, MD, Carolyn B. Bridges, MD, LaDora Woods (Immunization Services Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, Georgia), and Kathleen H. Harriman, PhD, MPH, RN (California Department of Public Health, Richmond, California). Drs. Kim, Bridges, and Harriman authored this work. For a list of members of the ACIP and the ACIP Adult Immunization Work Group, see the Appendix.

From the Centers for Disease Control and Prevention, Atlanta, Georgia.

Disclosures: To assure the integrity of the ACIP, the U.S. Department of Health and Human Services has taken steps to assure that there is technical adherence to ethics statutes and regulations regarding financial conflicts of interest. Concerns regarding the potential for the appearance of a conflict are addressed, or avoided altogether, through pre- and postappointment considerations. Individuals with particular vaccine-related interests will not be considered for appointment to the committee. Potential nominees are screened for conflicts of interest, and if any are found, they are asked to divest or forgo certain vaccine-related activities. In addition, at the beginning of each ACIP meeting, each member is asked to declare his or her conflicts. Members with conflicts are not permitted to vote if the conflict involves the vaccine or biological being voted on. Details can be found at www.cdc.gov/vaccines/acip/committee/structure-role.html. Drs. Kim, Bridges, and Harriman authored this work. Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-3005.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

In October 2015, the Advisory Committee on Immunization Practices (ACIP) approved the Recommended Adult Immunization Schedule: United States, 2016. This schedule summarizes ACIP recommendations for the use of vaccines routinely recommended for adults in 2 figures (Figures 1 and 2), footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults (Table). Details on these updates and information on other vaccines recommended for adults can be found at www.cdc.gov/vaccines/schedules. The full ACIP recommendations for each vaccine are not included in the schedule owing to space limitations but can be found at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The 2016 adult immunization schedule was reviewed and approved by the American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.

Figure 1.

Recommended immunization schedule for adults aged 19 years or older, by vaccine and age group.

Figure 2.

Vaccines that might be indicated for adults based on medical and other indications.

Footnotes.

Footnotes to the Recommended Immunization Schedule for Adults Aged 19 Years and Older: United States, 2016.

Footnotes.

Footnotes–Continued

Footnotes.

Footnotes–Continued

Footnotes.

Footnotes–Continued

Table. Contraindications and Precautions to Commonly Used Vaccines in Adults*†‡

Table. Contraindications and Precautions to Commonly Used Vaccines in Adults*†‡

Changes in the 2016 adult immunization schedule from the 2015 schedule include the following new ACIP recommendations:

• Serogroup B meningococcal (MenB) vaccine series should be administered to persons aged ≥10 years who are at increased risk for serogroup B meningococcal disease (2). Those at increased risk include persons with anatomical or functional asplenia or persistent complement component deficiencies, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, and persons identified at increased risk because of a serogroup B meningococcal disease outbreak. MenB vaccine series may be administered to adolescents and young adults aged 16 through 23 years (preferred age is 16 through 18 years) to provide short-term protection against most strains of serogroup B meningococcal disease (3).

• The row for “Meningococcal” was retitled to “Meningococcal 4-valent conjugate (MenACWY) or polysaccharide (MPSV4)” to indicate that there are 2 types of serogroup A, C, W, and Y meningococcal vaccines available for adults.

• A new row for “Meningococcal B (MenB)” was added.

• Additional text was added in several indication bars to describe reasons for alternate dosing schedules for vaccines where such designations were appropriate; for example, in the “Measles, mumps, and rubella (MMR)” indication bar that states “1 or 2 doses,” the clause “depending on indication” was added.

• The text in the “Hepatitis A” indication bar was revised from “2 doses” to “2 or 3 doses depending on vaccine” to account for the hepatitis A and hepatitis B combination vaccine that is administered in a 3-dose series.

• The text in the consolidated “Influenza” indication bar was simplified to “one dose annually”; readers should refer to the footnotes for additional information regarding which influenza vaccine types are recommended for different age and risk groups.

• The text in the “Pneumococcal polysaccharide (PPSV23)” indication bar was revised from “1 or 2 doses” to “1, 2, or 3 doses depending on indication” to account for the recommendation that adults aged ≥19 years with immunocompromising conditions or anatomical or functional asplenia can receive up to 3 doses of PPSV23.

• The text in the “Haemophilus influenzae type b (Hib)” indication bar was revised from “1 or 3 doses” to “3 doses, post-HSCT [hemapoietic stem cell transplant] recipients only” as these adults are the only group for whom a 3-dose series of Hib vaccination is recommended; for adults in other groups for whom Hib vaccination is recommended, the text in the indication bar was revised to “1 dose.”

The influenza, pneumococcal, meningococcal, and HPV vaccination sections are revised in the footnotes. The 2016 ACIP recommendations on influenza vaccination reiterate that all persons aged ≥6 months are recommended to receive annual vaccination against influenza (5). Persons aged ≥18 years with egg allergy of any severity may receive the recombinant influenza vaccine (RIV) because it does not contain any egg protein. Persons with hives-only allergy to eggs may receive the inactivated influenza vaccine (IIV) with additional safety measures.

The 2016 schedule footnotes correct 2 errata on pneumococcal vaccination that were in the 2015 schedule footnotes:

• “Adults aged ≥19 years” replaced “adults aged 19 through 64 years” as the age group for pneumococcal vaccination recommendations for persons with immunocompromising conditions, anatomical or functional asplenia, cerebrospinal fluid leak, or cochlear implant (6). The interval from PCV13 vaccination to PPSV23 vaccination is at least 8 weeks for adults aged ≥19 years with these conditions. For adults aged ≥65 years without these conditions, the interval from PCV13 vaccination to PPSV23 vaccination is at least 1 year.

• “Adults aged 19 through 64 years who are residents of nursing homes and other long-term care facilities” was removed from those for whom PPSV23 is recommended. These adults should be assessed for pneumococcal vaccination status and receive pneumococcal vaccines recommended based on their health condition(s) or age (6).

The footnotes in the 2016 schedule for meningococcal vaccination include new recommendations on the use of MenB vaccine, in addition to the information on the use of MenACWY and MPSV4 vaccines. Certain groups of persons known to be at increased risk for meningococcal disease are recommended to be routinely vaccinated with a MenACWY vaccine, which protects against meningococcal serogroups A, C, W, and Y (7). Although the epidemiology for meningococcal serogroup B is different from serogroups A, C, W, and Y, persons who are at increased risk for serogroup A, C, W, and Y meningococcal disease may also be at increased risk for serogroup B meningococcal disease. The footnotes for meningococcal vaccination in the 2016 schedule include the following general information:

• MenACWY vaccine is preferred over MPSV4 vaccine for adults with meningococcal vaccine indications who are aged ≤55 years, and for adults aged ≥56 years who were vaccinated previously with MenACWY vaccine and are recommended for revaccination or for whom multiple doses of vaccine are anticipated; MPSV4 vaccine is preferred for adults aged ≥56 years who have not received MenACWY vaccine previously and who require a single dose only (for example, persons at risk because of an outbreak).

• Revaccination with MenACWY vaccine every 5 years is recommended for adults previously vaccinated with MenACWY or MPSV4 vaccine who remain at increased risk for infection (for example, adults with anatomical or functional asplenia or persistent complement component deficiencies and microbiologists who are routinely exposed to isolates of Neisseria meningitidis).

• MenB vaccine is available as a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp vaccine; the 2 MenB vaccines are not interchangeable, that is, the same MenB vaccine product must be used for all doses.

• There is no recommendation for MenB revaccination at this time.

• MenB vaccine may be administered concomitantly with MenACWY vaccine, but at a different anatomical site, if feasible.

• HIV infection is not an indication for routine vaccination with MenACWY or MenB vaccine; if an HIV-infected person of any age is to be vaccinated, administer 2 doses of MenACWY vaccine at least 2 months apart.

• MenB vaccines are approved by the U.S. Food and Drug Administration for use in persons aged 10 through 25 years; however, because there is no theoretical difference in safety for persons aged >25 years compared with those aged 10 through 25 years, MenB vaccine is recommended by the ACIP for routine use in persons aged ≥10 years who are at increased risk for serogroup B meningococcal disease.

The meningococcal vaccination footnotes provide an algorithm for groups of persons known to be at increased risk for meningococcal disease:

• Adults with anatomical or functional asplenia or persistent complement component deficiencies: administer 2 doses of MenACWY vaccine at least 2 months apart and revaccinate every 5 years; in addition, administer either a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp vaccine.

• Microbiologists who are routinely exposed to isolates of Neisseria meningitidis: administer a single dose of MenACWY vaccine; revaccinate with MenACWY vaccine every 5 years if they remain at increased risk for infection; in addition, administer either a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp vaccine.

• Persons at risk because of a meningococcal disease outbreak: administer a single dose of MenACWY vaccine if the outbreak is attributable to serogroup A, C, W, or Y; if the outbreak is attributable to serogroup B, administer either a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp vaccine.

• Persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic: administer a single dose of MenACWY vaccine and revaccinate with MenACWY vaccine every 5 years if they remain at increased risk for infection; MenB vaccine is not recommended because meningococcal disease in these countries is generally not caused by serogroup B.

• Military recruits: administer a single dose of MenACWY vaccine.

• First-year college students aged ≤21 years who live in residence halls: administer a single dose of MenACWY vaccine if they have not received a dose on or after their 16th birthday.

• Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) may be vaccinated with either a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp vaccine to provide short-term protection against most strains of serogroup B meningococcal disease.

The footnotes in the 2016 adult immunization schedule for HPV vaccination include the following:

• Three HPV vaccines are licensed for use in females (2vHPV, 4vHPV, and 9vHPV) and two are licensed for use in males (4vHPV and 9vHPV).

• For females, 2vHPV, 4vHPV, or 9vHPV is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 26 years if not previously vaccinated.

• For males, 4vHPV or 9vHPV is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 21 years, if not previously vaccinated. Males aged 22 through 26 years may be vaccinated.

• HPV vaccination is recommended for men who have sex with men through age 26 years who did not get any or all doses when they were younger.

• Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 26 years who did not get any or all doses when they were younger.

• A complete HPV vaccination series consists of 3 doses. The second dose should be administered 4 to 8 weeks (minimum interval of 4 weeks) after the first dose; the third dose should be administered 24 weeks after the first dose and 16 weeks after the second dose (minimum interval of 12 weeks).

• HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the HPV vaccination series, no intervention is needed; the remainder of the 3-dose series should be delayed until completion or termination of pregnancy.

Lastly, a row for MenACWY/MPSV4 vaccine and a separate row for MenB vaccine replace the single row for meningococcal vaccine in the 2015 schedule table of contraindications and precautions to commonly used vaccines in adults. The text “Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component” was added as a contraindication and “Moderate or severe acute illness with or without fever” was added as a precaution for both MenACWY/MPSV4 and MenB rows.

The adult immunization schedule describes certain conditions that might cause altered immunocompetence, such as anatomical or functional asplenia and the use of immunosuppressive drugs, as indications or contraindications for specific vaccines. It also describes certain high-risk conditions for which specific vaccines are recommended. For example, before all adults were recommended to receive yearly influenza vaccine—a recommendation since the 2010–2011 influenza season—the ACIP recommended that adults who are at increased risk for severe complications from influenza or at higher risk for influenza-related outpatient, emergency department, or hospital visits receive annual influenza vaccine, including those with chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus), and HIV infection (8). The ACIP also recommends that women who are or will be pregnant during the influenza season be vaccinated to protect themselves and their newborns (5, 8). In addition, tetanus–diphtheria–acellular pertussis (Tdap) vaccination is recommended for pregnant women during each pregnancy, preferably during 27 to 36 weeks' gestation, regardless of her history of receiving tetanus–diphtheria (Td) or Tdap vaccines (9). Thus, obstetrician-gynecologists, pulmonologists, nephrologists, cardiologists, and other clinical specialists who provide care for these at-risk adult populations have the responsibility, as do their primary care colleagues, to assess for and recommend vaccines their patients need, and either administer the needed vaccines or refer them to a place where they can get the recommended vaccines. Recently, the authors of 2 published meta-analyses described an association between influenza vaccination and lower risk for cardiovascular events among patients with existing cardiovascular disease. They concluded that physicians should be aware of the need to offer influenza vaccination to patients with cardiovascular disease and that cardiologists should offer vaccination to their patients as “a simple once-annual protective therapy to reduce cardiovascular events” (10, 11).

Despite the long-standing ACIP recommendations and continued emphasis on vaccinating adults who are at increased risk for complications from influenza, influenza vaccination coverage rates among high-risk adults have remained low (12, 13). The overall influenza vaccination coverage for the 2012–2013 season among adults 18 through 64 years of age with at least 1 high-risk condition was only 49.5% and those with at least 2 high-risk conditions was only 59.5% (13). Influenza vaccination rates were low among those with lung disease (46.2%), heart disease (50.5%), diabetes (58.0%), renal disease (62.5%), and cancer (56.4%). In 2012–2013, out of an estimated 40 million adults 18 through 64 years of age with medical conditions that increase the risk for severe illness from influenza, approximately 90% of those who were unvaccinated may have missed at least 1 potential opportunity to receive the influenza vaccine through their health care provider (13). Coverage rates for other vaccines indicated for adults 18 through 64 years of age who have high-risk conditions are likewise low (14). For adults ≥19 years of age with chronic liver conditions, only 13.3% reported that they received hepatitis A vaccinations and 34.0% reported that they received hepatitis B vaccinations. Hepatitis B vaccination coverage among adults aged 19 through 59 years and ≥60 years with diabetes was 26.3% and 13.9%, respectively.

Although vaccination coverage estimates for adults with high-risk conditions are low, almost all general internists and family physicians feel responsible to ensure that patients receive recommended vaccines (15). But only 29% of general internists and 32% of family physicians assess their adult patients' vaccination status at every visit (15). In addition, some adult patients may rely on the specialists they see for primary care, including vaccination. A recommendation by an adult patient's health care provider for needed vaccines is a strong predictor of the patient receiving recommended vaccines (16). The health care provider is clearly the central figure in promoting vaccination among adults with high-risk conditions and adults in general.

Several tools are available to assist primary care and specialty health care providers in assessing for and recommending needed vaccines for their adult patients (17–19). Health care providers also have at their disposal proven methods for improving vaccination rates, such as the use of standing orders, patient reminder and recall notices, provider feedback, and immunization information systems (commonly known as vaccine registries, which are available in most states) (20). In addition, electronic health record management systems can include adult immunization and clinical decision-support systems to prompt providers to assess their patients' immunization needs and recommend appropriate vaccinations. Because only 31% of family physicians and 20% of general internists reported stocking all vaccines routinely recommended for adults (15), many providers will need to refer some of their patients to other providers for vaccination. Online tools, such as Vaccine Finder (www.vaccines.gov/more_info/features/healthmapvaccinefinder.html), can be useful for providers to identify vaccination service providers in their area.

Primary care providers and specialty providers, such as obstetrician-gynecologists, cardiologists, and other clinical specialists, have the responsibility to help ensure that their patients are protected from vaccine-preventable diseases and their sequelae. The use of proven, existing strategies can lead to improvements in immunization coverage rates and reduced illness and disability from vaccine-preventable diseases among adults in the United States.

Appendix

Recommendations for routine use of vaccines in children, adolescents, and adults are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the Centers for Disease Control and Prevention (CDC) on use of vaccines and related agents for the control of vaccine-preventable diseases in the civilian population of the United States. Recommendations for routine use of vaccines in children and adolescents are harmonized to the greatest extent possible with recommendations made by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG). Recommendations for routine use of vaccines in adults are harmonized with recommendations of AAFP, ACOG, and the American College of Physicians (ACP). ACIP recommendations adopted by the CDC Director become agency guidelines on the date published in the Morbidity and Mortality Weekly Report (MMWR). Additional information on ACIP is available at www.cdc.gov/vaccines/acip.

* The 2016 ACIP Adult Immunization Schedule appears in Annals of Internal Medicine and on the Centers for Disease Control and Prevention Web site at www.cdc.gov/vaccines/schedules. An announcement summarizing changes in the 2016 adult immunization schedule is published concurrently in the Morbidity and Mortality Weekly Report. Readers can cite the 2016 adult immunization schedule as follows: Kim DK, Bridges CB, Harriman KH; Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practice recommended immunization schedule for adults aged 19 years or older: United States, 2016. Ann Intern Med. 2016;164:184-94. doi:10.7326/M15-3005

† The 2016 adult immunization schedule was prepared by the Advisory Committee on Immunization Practices (ACIP); ACIP Adult Immunization Work Group; David K. Kim, MD, Carolyn B. Bridges, MD, LaDora Woods (Immunization Services Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, Georgia), and Kathleen H. Harriman, PhD, MPH, RN (California Department of Public Health, Richmond, California). Drs. Kim, Bridges, and Harriman authored this work. For a list of members of the ACIP and the ACIP Adult Immunization Work Group, see the Appendix.

Figure 1.

Recommended immunization schedule for adults aged 19 years or older, by vaccine and age group.

Figure 2.

Vaccines that might be indicated for adults based on medical and other indications.

Footnotes.

Footnotes to the Recommended Immunization Schedule for Adults Aged 19 Years and Older: United States, 2016.

Footnotes.

Footnotes–Continued

Footnotes.

Footnotes–Continued

Footnotes.

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Table. Contraindications and Precautions to Commonly Used Vaccines in Adults*†‡

Table. Contraindications and Precautions to Commonly Used Vaccines in Adults*†‡

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